Citation Nr: 21011312 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 14-28 360A DATE: March 1, 2021 REMANDED Entitlement to service connection for a chest disorder characterized as scars, status post chest surgeries for gynecomastia for substitution or accrued benefits purposes is remanded. Entitlement to service connection for a left shoulder disorder for substitution or accrued benefits purposes is remanded. Entitlement to service connection for a right shoulder disorder for substitution or accrued benefits purposes is remanded. Entitlement to service connection for a heart disorder for substitution or accrued benefits purposes is remanded. Entitlement to service connection for an ulcer disorder for substitution or accrued benefits purposes is remanded. Entitlement to service connection for a gastrointestinal disorder for substitution or accrued benefits purposes is remanded. Entitlement to service connection for a liver disorder for substitution or accrued benefits purposes is remanded. Entitlement to service connection for prostate cancer for substitution or accrued benefits purposes is remanded. Entitlement to service connection for an acquired psychiatric disorder to include anxiety for substitution or accrued benefits purposes is remanded. Entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, for substitution or accrued benefits purposes is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) for substitution or accrued benefits purposes is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from September 1982 to February 1986 and October 2008 to April 2009. He had additional periods of inactive duty for training (INACDUTRA) and active duty for training (ACDUTRA) in the United States Naval Reserve from February 1986 and September 2010. The Veteran died in February 2018. The appellant is his surviving spouse who has been substituted for him in this matter in accordance with 38 U.S.C. § 5121A. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from December 2011 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in St. Petersburg, Florida. It is noted that some of the Veteran's service treatment records may be unavailable. As such, there is a heightened obligation to assist the appellant the development of the claim, a heightened obligation to explain findings and conclusions, and to consider carefully the benefit of the doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). This matter was previously before the Board in May 2019 at which time it was remanded for additional development. It is now returned to the Board. 1. Entitlement to service connection for a chest disorder characterized as scars, status post chest surgeries for gynecomastia. The Veteran had asserted that he had a chest condition that was related to active service. In February 2013, he stated that he had scarring over the right and left breast due to a March 2009 surgical procedure. Enlistment physical examination dated in December 1980 shows that the Veteran had gynecomastia on entrance that was not considered disqualifying. Additional service treatment records reflect that he underwent surgical procedures in February 1985 and March 2009 for bilateral gynecomastia and had scarring from those procedures. A July 1985 service treatment record reflects a diagnosis of suspect surgical neuromas. A history of bilateral mastectomy for benign gynecomastia in February 1985 was noted showing a full recovery. The Veteran had reported persistent tenderness, bilaterally. The symptoms, which were exacerbated three to four weeks earlier, included shirt friction. Physical examination revealed thickening of the right periareolar and inverted left nipple. An August 1985 service treatment record reveals that he had a scar following the February 1985 gynecomastia surgical procedure. February 2009 service treatment records reflect diagnoses of breast appearance hypertrophy. The treatment providers noted a history of surgical correction of gynecomastia more than ten years earlier and that the Veteran wanted a referral for another procedure to resolve his condition. A March 2009 private treatment record reflects a normal mammogram and ultrasound of the breasts. March 2009 private treatment records reflect that he underwent a surgical procedure for bilateral gynecomastia. Post-service treatment records reflect that the Veteran continued to have scarring from the February 1985 and March 2009 surgical procedures. An October 2014 VA treatment record reflects a diagnosis of gynecomastia. Physical examination revealed bilateral gynecomastia with horizontal surgical scars slightly spread. A VA medical opinion dated in May 2020 shows that a VA examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that the Veteran’s chest scars from surgeries for gynecomastia constituted the usual effects of ameliorative surgery. The debulking done for relief (amelioration) of gynecomastia involved cutting the skin and fatty layer of the chest wall, leading to the scars noted in the Veteran’s claims file. The examiner could not identify in-service injury, incident or other evidence of any aggravation of the scar. There was no evidence that the service somehow led to scar instability, growth, or other evidence of unnatural aggravation. In correspondence received in September 2020, the appellant asserted that the May 2020 VA examiner failed to consider the lay evidence of record, to include the written testimony of the Veteran indicated that increasing pain and irritation of the condition impacted his daily activities, including but not limited to shirt friction. Indeed, he had to undergo a subsequent bilateral gynecomastia in March 2009 as a result of the aggravation of the residuals of the initial surgical procedure, that included avoidance of physical contact of people or objects with the chest due to pain and sensitivity. The Board agrees with the appellant and finds that the VA examiner did not discuss the lay evidence of record in support of the Veteran’s claim. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant’s report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, on remand, an opinion must be obtained as to why there was a need for a second corrective surgical procedure in 2009 following the initial surgical procedure in 1985. As such, a new medical opinion must be provided. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). See also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (once VA provides an examination, VA has a duty to ensure that the examination is adequate for evaluation purposes); Hicks v. Brown, 8 Vet. App. 417, 422 (1995) (inadequate medical evaluation frustrates judicial review).   2. Entitlement to service connection for a left shoulder disorder. 3. Entitlement to service connection for a right shoulder disorder. The Veteran had asserted that he had left and right shoulder disorders that were first manifested during his period of active service. In August 2012, he stated that he had left and right shoulder disorders due to 28 years of push-ups in service. An undated service treatment record, which appears to have been written in the early 1990s, reflected a diagnosis of back upper strain. An August 2012 private treatment record reflects a diagnosis of left shoulder impingement syndrome and right shoulder pain. A VA examination report dated in May 2020 shows that a VA examiner opined that that the claimed shoulder disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that he could not identify any specific records of chronic or recurrent shoulder problems beginning or within a year following discharge. The examiner added that there was no evidence that the upper back strain had anything to do with the significant pathology noted in a 2013 diagnostic study. The left shoulder disorder was thought to have begun around 2010. The examiner added that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner provided the same explanation for this conclusion as provided for the direct opinion above. In correspondence received in September 2020, the appellant asserted that the May 2020 VA examiner failed to consider the lay evidence of record. Additionally, the appellant suggested that the asserted shoulder disorders were secondary to the claimed chest disorder. In this regard, it was posited that the scarring, chest contraction and pain was a major inhibitor of use of the shoulders. The Veteran was said to have reported on numerous occasions that he experienced restrictions with reaching and lifting any weight more than five or ten pounds. The appellant also noted that the VA examiner’s opinion was conclusory and not accompanied by a detailed rationale. The Board agrees with the appellant and finds that the VA examiner did not discuss the lay evidence of record in support of the Veteran’s claim. See Dalton, 21 Vet. App. at 23. Additionally, the examiner has raised an additional theory of entitlement in that the left and right shoulder disorders were secondary to the asserted service connection claim for a chest disorder. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). As such, a new medical opinion must be provided. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; see also Barr, 21 Vet. App. at 311; Hicks, 8 Vet. App. at 422. 4. Entitlement to service connection for a heart disorder. The Veteran had asserted that he had a heart disorder that was first manifested during his periods of active service. A February 2001 doppler echocardiogram revealed mild mitral valve prolapse, mild mitral regurgitation; and an ejection fraction of 60 percent. A March 2009 echocardiogram revealed sinus bradycardia; minimal voltage criteria for left ventricular hypertrophy, and a nonspecific T wave abnormality. A VA examination report dated in May 2020 shows that a VA examiner opined that the claimed mitral valve regurgitation and left ventricular hypertrophy were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The regurgitation preceded the service as noted in a 2001 echocardiogram, the left ventricular hypertrophy found in the 2009 echocardiogram resolved by 2017 due to hypertension control. There was no evidence of any in-service cardiac condition. The examiner also opined that the claimed mitral valve regurgitation condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that mitral regurgitation was a very common incidental finding in echocardiograms affecting nearly half the population according to some studies. The condition was not pathological, and the valve findings were consistently unchanged in between the 2001 and 2017 echocardiogram studies. The minimal left ventricular hypertrophy noted in 2009 appeared to have resolved by 2017 with proper hypertension control. The examiner found no objective evidence of aggravation, and the Veteran’s statement of aggravation was not supported by any objective evidence in the claims file showing some sort of aggravation of the pre-existing condition. In correspondence received in September 2020, the appellant asserted that the May 2020 VA examiner found that the Veteran’s heart condition somehow did not exist or was not aggravated during the Veteran’s periods of service, but somehow arose outside of those periods. It was suggested that in conclusionary findings, it was determined that the heart issues somehow did not arise during periods of service or skipped over such periods, and when considered within a period of service the cardiac issues were found to be stable and non-aggravated. The Board finds the opinion of the VA examiner to be incomplete as it was suggested the left ventricular hypertrophy noted in 2009 appeared to have resolved by 2017. In this regard, the Veteran had filed his claim in January 2012. The VA examiner failed to address whether the Veteran had the left ventricular hypertrophy at any point during the claim prior to 2017, and if so, whether it was etiologically related to the findings during active service in 2009. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the current disability requirement is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). As such, a new medical opinion must be provided. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; see also Barr, 21 Vet. App. at 311; Hicks, 8 Vet. App. at 422. 5. Entitlement to service connection for an ulcer disorder. 6. Entitlement to service connection for a gastrointestinal disorder. 7. Entitlement to service connection for a liver disorder. The Veteran had asserted that he had an ulcer and a gastrointestinal disorder that were related to his periods of active service. He had also asserted that he had liver cysts that were etiologically related to his periods of active service. In October 2010, he indicated that he was treated for an ulcer in 1986. In January 2012, he stated that he took Ranitidine daily to control flare-ups for multiple years. Service treatment records dated in October 1984 show a diagnosis of abdominal pain of unknown etiology. The Veteran had been complaining of nausea, fever, and diarrhea. An October 1991 report of medical history shows that the Veteran indicated that he had stomach, liver, or intestinal trouble. In September 1994, he reported that he took Tagamet for his stomach. An October 2002 computed tomography (CT) scan of the lumbar spine revealed a small hypodensity in the periphery of the liver. VA outpatient treatment records dated in October 2002 reflect a history of peptic ulcer disease in 1969 and 1995; and had an active prescription of Ranitidine. In October 2003, he reported he had been treated for an ulcer in 1986 with Zantac. A May 2007 X-ray revealed a slight deformity of the duodenal bulb related with the story of chronic peptic disease. A May 2011 CT scan of the abdomen revealed a subcentimeter cyst involving the right lobe of the liver. A February 2012 VA treatment record reflects a diagnosis of esophagitis. The treatment provider noted that the Veteran had occasional reflux. A January 2015 CT scan of the abdomen and pelvis revealed subcentimeter hypodensities noted within the liver that were too small to characterize. The treatment provider opined that they likely represented cysts. An April 2016 VA treatment record reflects a diagnosis of gastroesophageal reflux disease. A VA examination report dated in May 2020 shows that a VA examiner opined that the claimed esophagitis, gastritis, and hiatal hernia was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had no stomach ulcer, nor had he ever had imaging confirmation of an ulcer. The current conditions were said to have been found in post-discharge records with no evidence of chronic esophagus or stomach problems noted in the service or immediate post-discharge records to correlate to the findings identified in the 2012 esophagogastroduodenoscopy. The examiner also concluded that the claimed esophagitis, gastritis, and hiatal hernia that clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner provided an identical explanation as above for the conclusion reached, adding that there was no objective evidence to support aggravation of the condition due to the service. A VA examination report dated in May 2020 shows that a VA examiner opined that it was less likely than not that any liver cyst manifested during active service, or was otherwise causally or etiologically related to a period of active service. The examiner explained that imaging done from 2002 showed a small hypodensity in the liver as an incidental finding. The lesion was still too small to characterize in 2015. There was no evidence of growth of the lesion in the interim found, and no evidence that somehow the service caused an “unnatural aggravation” of the lesion. In correspondence received in September 2020, the appellant asserted that even if the May 2020 VA examiner was accurate in concluding there was no definitive finding of an ulcer, there was no discussion or analysis of the Veteran’s other well documented medical issues or his statements concerning these issues. The Board agrees that the examiner did not provide an opinion explaining whether the abdominal and gastrointestinal symptoms experienced in service were related to the post-service findings demonstrated by the Veteran. As such, the opinion is of limited probative value, and a new medical opinion must be provided. Additionally, the VA examiner did not address whether any of the abdominal or gastrointestinal symptoms reported by the Veteran could have been etiologically related to the liver cysts that were manifested during service. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; see also Barr, 21 Vet. App. at 311; Hicks, 8 Vet. App. at 422. 8. Entitlement to service connection for prostate cancer. The Veteran had asserted that his prostate cancer was etiologically related to his period of active service. In September 2011, he stated that he had been treated for prostate cancer that had been diagnosed within one month of his discharge from active service. A June 2014 private treatment record shows that the Veteran had a diagnosis of adenocarcinoma of the prostate, that was definitely diagnosed with a biopsy in 2011. The treatment provider opined that the Veteran’s prostate-specific antigen (PSA) levels had been steadily rising since 2007, and that it was more likely than not that he had an existing undiagnosed prostate cancer in the years preceding his 2011 biopsy. A VA examination report dated in May 2020 shows that a VA examiner opined that the claimed prostate cancer was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had an enlarged prostate in 2004 before service, thus, there was a strong likelihood the condition existed prior to service. The examiner added that there was no evidence it manifested or existed during active service, and there was no evidence that the cancer somehow manifested or grew due to the or in the service. The examiner added that the pre-existing prostate cancer was not aggravated in service beyond the natural progression of such disorder during such service. In correspondence received in September 2020, the appellant asserted that the opinion of the VA examiner was essentially devoid of reasoning and was contradictory when viewed in conjunction of the other evidence of record. The Board agrees that the examiner’s opinion is of limited probative value as it does not provide an explanation as to why having an enlarged prostate in 2004 prior to his second period of active service is conclusive of the fact that he had prostate cancer before entering that period of active service. Moreover, the opinion does not address the June 2014 favorable evidence of record that suggests a likelihood the Veteran had an existing undiagnosed prostate cancer in the years preceding his 2011 biopsy, and the Veteran’s statements that he had been treated for prostate cancer that had been diagnosed within one month of his discharge from active service. Also, the opinion does not provide an explanation for the conclusion that the pre-existing prostate cancer was not aggravated in service beyond the natural progression of such disorder during such service. As such, a new medical opinion must be provided. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion. Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; see also Barr, 21 Vet. App. at 311; Hicks, 8 Vet. App. at 422. 9. Entitlement to service connection for an acquired psychiatric disorder to include anxiety. The Veteran had asserted that he had manifested symptoms associated with a psychiatric disorder during his period of active service. He additionally contended that he had been experiencing such symptoms secondary to his many asserted service-connected disabilities. In January 2012, he attributed his symptoms to emotional trauma associated with his prostate cancer diagnosis. Service treatment records from periods of Reserve service dated from 1993 to 2007 show that the Veteran was taking Valium and also experiencing sleep disturbance. Post-service VA outpatient treatment records confirm intermittent assessments of major depressive disorder and anxiety related to his declining physical condition. In correspondence received in September 2020, the appellant asserted that the Veteran experienced understandable anxiety concerning his prostate cancer and other medical conditions. He was prescribed various anti-depressant and psychotropic medications to cope with his anxiety. He was said to have limited his social interactions due to his anxiety, depression, and occasional paranoia. In light of the contentions of the Veteran and the appellant, and given the record on appeal, a VA opinion should be obtained to determine the probable etiology of the Veteran’s asserted psychiatric disorder, to include whether he had a pre-existing disorder that was aggravated by his second period of active service, and whether he had a psychiatric disorder secondary to a service-connected disability. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159(c)(4)(i). Additional Development It is noted that February 2011, the RO filed a request for records of the Veteran with the Navy Medical Center Portsmouth, Portsmouth, Virginia. In the request, the RO asked for all records dated from 2005 to 2010. In correspondence from the Department of the Navy, Naval Medical Center, in Portsmouth, Virginia, received in March 2011, it was indicated that inpatient records for the Veteran did exist, but not for the dates in the request. It is not apparent what other records for the Veteran did exist, and whether those records were ever obtained. As such, on remand, a request should be directed to the Navy Medical Center Portsmouth to provide all available records of the Veteran for all dates. 10. Entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, for substitution or accrued benefits purposes. 11. Entitlement to a TDIU. The claims of entitlement to assignment of a combined disability rating greater than 60 percent, prior to January 9, 2012, and greater than 80 percent, thereafter, and entitlement to a TDIU, are inextricably intertwined with the claims of entitlement to service connection being remanded herein. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, action on the claims are deferred pending completion of the additional development. The matters are REMANDED for the following action: 1. Request that the Department of the Navy, Naval Medical Center, in Portsmouth, Virginia, provide all medical records for the Veteran, regardless of date. If the requested records are not available, or if the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file, and the appellant informed in writing. The appellant may submit any additional medical records directly to VA. 2. Obtain a VA medical opinion to ascertain the etiology of the Veteran’s asserted chest disorder, status post chest surgeries for gynecomastia. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. The examiner must opine whether it is at least as likely as not that the residuals from the chest surgeries experienced by the Veteran were manifested during a period of active service. If the examiner finds that the asserted disability clearly and unmistakably pre-existed service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. In doing so, the examiner must explain why there was a need for a second corrective surgical procedure in 2009 following the initial surgical procedure in 1985. If the examiner finds that it either did not clearly and unmistakably pre-exist service, or was not clearly and unmistakably aggravated by service, the examiner must opine as to whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner is advised that the Veteran, as well as those providing lay statements on his behalf, were competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If the examiner rejects any reports of symptomatology, a reason for doing so must be provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 3. Obtain a VA opinion to ascertain the etiology of the Veteran’s asserted left and right shoulder disorders. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. The examiner should answer all of the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran's diagnosed left and right shoulder disorders had onset in service, had onset in the year immediately following any period of service, or are otherwise the result of a disease or injury in service? (b) Is it at least as likely as not that the Veteran's diagnosed left and right shoulder disorders were caused (in whole or in part) by the asserted chest disorder, status post chest surgeries for gynecomastia? (c) Is it at least as likely as not that the Veteran's diagnosed left and right shoulder disorders were aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by the asserted chest disorder, status post chest surgeries for gynecomastia? If the Veteran's left and right shoulder disorders were aggravated by the asserted chest disorder, status post chest surgeries for gynecomastia, the examiner should also indicate, to the extent possible, the level of such aggravation by identifying a baseline level of disability. The examiner is advised that the Veteran and those providing lay evidence were competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the reports of symptomatology, a reason for doing so must be provided. The absence of evidence of treatment for a specific shoulder disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 4. Obtain a VA medical opinion to ascertain the etiology of the Veteran’s asserted heart disorder. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. The examiner must opine whether it is at least as likely as not that a heart disorder, manifested by mitral valve prolapse, mitral regurgitation, sinus bradycardia, left ventricular hypertrophy, and/or a nonspecific T-wave abnormality, experienced by the Veteran were manifested during a period of active service. If the examiner finds that the asserted disability clearly and unmistakably pre-existed service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. If the examiner finds that it either did not clearly and unmistakably pre-exist service, or was not clearly and unmistakably aggravated by service, the examiner must opine as to whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner is specifically requested to determine whether it is at least as likely as not that the diagnosed left ventricular hypertrophy noted in 2009, and appeared to have resolved by 2017, had been manifested at any time since January 2012. If so, the examiner is requested to opine as to whether it is at least as likely as not etiologically related to the in-service findings in 2009. The examiner is advised that the Veteran, as well as those providing lay statements on his behalf, were competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If the examiner rejects any reports of symptomatology, a reason for doing so must be provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 5. Obtain a VA medical opinion to ascertain the etiology of the Veteran’s asserted ulcer, gastrointestinal, and liver disorders. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. The examiner is requested to opine as to whether it is at least as likely as not that a gastrointestinal, ulcer, and/or liver disorder manifested during, is otherwise causally or etiologically related to, or aggravated by, a qualifying period of active duty service and/or ACDUTRA. The examiner is directed to consider and discuss the following: (a) The Veteran’s statements that he was treated for an ulcer in 1986; (b) Service treatment records that reflect the Veteran reported nausea and diarrhea from at least October 1984; (c) Post-service treatment records that reflect the Veteran was prescribed medication for his stomach from at least October 2002; (d) Post-service treatment records that reflect a diagnosis of esophagitis from at least February 2012 and gastroesophageal reflux disease from at least April 2016; (e) The October 2002 CT of the lumbar spine revealing a small hypodensity in the periphery of the liver. (f) The May 2011 CT of the abdomen revealing a subcentimeter cyst involving the right lobe of the liver; and (g) The January 2015 CT of the abdomen and pelvis revealing subcentimeter hypodensities noted within the liver that were too small to characterize, but that likely represented cysts. The examiner is advised that the Veteran, as well as those providing lay statements on his behalf, were competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If the examiner rejects any reports of symptomatology, a reason for doing so must be provided. The absence of evidence of treatment for a particular ulcer, gastrointestinal, or liver disorder in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 6. Obtain a VA medical opinion to ascertain the etiology of the Veteran’s prostate cancer. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. The examiner should answer all of the following questions as definitively as possible: (a) Whether prostate cancer clearly and unmistakably (obvious, manifest, undebatable) existed prior to the Veteran’s period of active service from October 2008 to April 2009. (b) If the examiner determines that there is clear and unmistakable evidence that the Veteran’s prostate cancer pre-existed active service, is there clear and unmistakable evidence that the pre-existing prostate cancer was NOT aggravated in service beyond the natural progression of such disorder during such service. (c) If there is no clear and unmistakable evidence that the Veteran had prostate cancer that pre-existed active service and was not aggravated in active duty service, is it at least as likely as not that the prostate cancer manifested during active service, was manifested to a compensable degree within one year of active service, or was otherwise causally or etiologically related to a period of active service. In rendering the opinions, the examiner is directed to consider and discuss the following: (1) The January 2004 service treatment record that reflects a diagnosis of an enlarged prostate; (2) The February 2009 service treatment record that reflects a diagnosis of male erectile disorder; (3) The March 2011 private treatment records that reflect a diagnosis of Gleason 8 prostate cancer and benign prostatic hypertrophy; and (4) The June 2014 private opinion that the Veteran’s PSA levels had been steadily rising since 2007, and it was more likely than not he had an existing undiagnosed prostate cancer in the years preceding his 2011 biopsy. The examiner is advised that the Veteran, as well as those providing lay statements on his behalf, were competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If the examiner rejects any reports of symptomatology, a reason for doing so must be provided. The absence of evidence of treatment for prostate cancer in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 7. Obtain a VA medical opinion to ascertain the etiology of the Veteran’s asserted psychiatric disorder. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. The examiner should answer all of the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran had a diagnosis of a psychiatric disorder, and if so, whether it had onset in service, onset in the year immediately following any period of service, or was otherwise the result of a disease or injury in service? (b) If the examiner finds that the Veteran had a psychiatric disorder that existed prior to a period of active service, the examiner must opine as to whether the psychiatric disorder clearly and unmistakably pre-existed service, and if so, whether it was clearly and unmistakably NOT aggravated by service. (c) If the examiner finds that it either did not clearly and unmistakably pre-exist service, or was not clearly and unmistakably aggravated by service, the examiner must opine as to whether it is at least as likely as not related to an in-service injury, event, or disease. In rendering an opinion, the examiner must consider the evidence of medication (valium) taken by the Veteran from 1993 to 2007. Additionally, the examiner is requested to provide an opinion as to the following: (1) Is it at least as likely as not that the Veteran’s diagnosed psychiatric disorder was caused (in whole or in part) by a service-connected disability? (2) Is it at least as likely as not that the Veteran’s diagnosed psychiatric disorder was aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability? If the Veteran’s psychiatric disorder was aggravated by a service-connected disability, the examiner should also indicate, to the extent possible, the level of such aggravation by identifying a baseline level of disability. The examiner is advised that the Veteran, as well as those providing lay statements on his behalf, were competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If the examiner rejects any reports of symptomatology, a reason for doing so must be provided. The absence of evidence of treatment for a specific psychiatric disorder in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Orfanoudis, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.